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Flat foot pain is a common complaint that requires therapeutic intervention. Currently, myofascial release techniques are often used in the therapy of musculoskeletal disorders. A group of 60 people suffering from flat feet with associated pain. Patients were assigned to four groups (15 people each): MF-myofascial release, E-the exercise program, MFE-myofascial release and the exercise program, C-no intervention. The rehabilitation program lasted 4 weeks. The NRS scale was used to examine pain intensity and FreeMed ground reaction force platform was used to examine selected static and dynamic foot indicators. Statistically significant pain reduction was obtained in all research. A static test of foot load distribution produced statistically significant changes only for selected indicators. In the dynamic test, statistically significant changes were observed for selected indicators, only in the groups subjected to therapeutic intervention. Most such changes were observed in the MF group. In the dynamic test which assessed the support phase of the foot, statistically significant changes were observed only for selected subphases. Most such changes were observed in the MFE group. Both exercise and exercise combined with myofascial release techniques, and especially myofascial release techniques alone, significantly reduce pain in a flat foot. This study shows a limited influence of both exercises and myofascial release techniques on selected static and dynamic indicators of a flat foot., (© 2022. The Author(s).)

A better understanding of soft tissue stress and its role in supporting the medial longitudinal arch in flexible flatfoot could help to guide the clinical treatment. In this study, a 3-Dimensional finite element (FE) foot model was reconstructed to measure the stress of the soft tissue, and its variation in different scenarios related to flexible flatfoot. All bones, cartilages, ligaments and related tendons around the ankle, and fat pad were included in the finite element model. The equivalent stress on the articular surface of the joints in the medial longitudinal arch and the maximum principal stress of the ligaments around the ankle were obtained. The results show that the plantar fascia (PF) is the main tissue in maintaining the medial longitudinal arch. The equivalent stress of all the joints in the medial longitudinal arch increases when the PF attenuation and the talonavicular joint increases, while other joints decreases when all the three tissue attenuation. Moreover, the maximum principal stress variation of calcaneofibular ligament is largest when the PF attenuation and the tibionavicular ligament and posterior tibiotalar ligament are largest when the posterior tibial tendon (PTT) attenuation. The maximum principal stress variation of tibionavicular ligament and posterior tibiotalar ligament are even larger when all the three tissue attenuation. These findings support that the PF is the main factor in maintaining the medial longitudinal arch. The medial longitudinal arch collapse mainly affects the talonavicular joint and the calcaneofibular ligament, the tibionavicular ligament and the posterior tibiotalar ligament. This approach could help to improve the understanding of adult-acquired flatfoot deformity (AAFD)., (© 2021. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Background: This study was performed to investigate the change in the bony alignment of the foot after tendo-Achilles lengthening (TAL) and the factors that affect these changes in patients with planovalgus foot deformity., Methods: Consecutive 97 patients (150 feet; mean age 10 years; range 5.1-35.7) with Achilles tendon contracture (ATC) and planovalgus foot deformity who underwent TAL were included. All patients underwent preoperative and postoperative weight-bearing anteroposterior (AP) or lateral (LAT) foot radiographics. Changes in AP talo-1st metatarsal angle, AP talo-2nd metatarsal angle, LAT talo-1st metatarsal angle, and calcaneal pitch angle and the factors affecting such changes after TAL were analyzed using lineal mixed model., Results: There were no significant change in AP talo-1st metatarsal angle and AP talo-2nd metatarsal angle after TAL in patients with cerebral palsy (CP) (p = 0.236 and 0.212). However, LAT talo-1st metatarsal angle and calcaneal pitch angle were significantly improved after TAL (13.0°, p < 0.001 and 4.5°, p < 0.001). Age was significantly associated with the change in LAT talo-1st metatarsal angle after TAL (p = 0.028). The changes in AP talo-1st metatarsal angle, AP talo-2nd metatarsal angle, and calcaneal pitch angle after TAL were not significantly associated with the diagnosis (p = 0.879, 0.903, and 0.056). However, patients with CP showed more improvement in LAT talo-1st metatarsal angle (- 5.0°, p = 0.034) than those with idiopathic cause., Conclusion: This study showed that TAL can improve the bony alignment of the foot in patients with planovalgus and ATC. We recommend that physicians should consider this study's findings when planning operative treatment for such patients.

Introduction: Flatfoot deformity is commonly characterized by a subtalar valgus, a low medial longitudinal arch, and abduction of the forefoot. Although flatfoot deformity has been associated with lower first (KAM1) and second (KAM2) peak knee adduction moments during walking, the biomechanical connection remains unknown., Research Question: We hypothesized that hindfoot eversion, lateral calcaneal shift correlate with KAM1 and forefoot abduction and arch height with KAM2, due to the lateralization of the ground reaction force vector resulting from shifted heel and forefoot in flatfoot deformity., Methods: Gait data from 103 children with flatfoot deformity who underwent three-dimensional gait analysis with the Oxford Foot Model were retrospectively included. Children with knee varus/valgus, in- and out-toeing were excluded. Fifteen healthy children with a rectus foot type were also collected from the database. Lateral calcaneal shift was defined as the distance between the projection of the ankle joint center onto the calcaneal axis and the midpoint of the calcaneal axis formed by the medial and lateral calcaneal markers. A subgroup of children with idiopathic flatfoot deformity that had received corrective surgery was also identified. Statistical analysis included Pearson's correlations and independent and paired t-tests (α < .05)., Results: When compared to a norm cohort, flatfooted children had significant lower KAM1 and KAM2 (t-test, P < .001). Lateral calcaneal shift correlated with KAM1 and KAM2 (r = 0.42, p < .001 and r = 0.32, P < .001, respectively). Arch height correlated with KAM2 (r = 0.23, p = 0.017). KAM1 and KAM2 normalized after surgery and the change in KAM1 correlated with the change in lateral calcaneal shift for children who underwent corrective surgery., Significance: Lateral calcaneal shift explains the reduction of KAM1 by lateralization of the point of force application in flatfooted children. It is recommended to consider the lateral calcaneal shift when investigating KAM in gait analysis research., (Copyright © 2020 Elsevier B.V. All rights reserved.)

Background: The tissue stress theory is commonly used to prescribe foot orthoses, however the mechanisms of foot orthoses are not understood well. The effect foot orthotics have on the plantar intrinsic muscles remains unclear. The study was designed to assess changes in muscle size and activity of the intrinsic muscles of individuals with pes planus after wearing custom-made foot orthotics for 12-weeks., Methods: Eighteen young adults with pes planus were allocated by stratified sampling into the orthotic group (n = 9) or control group (n = 9). Ultrasonography measured the cross-sectional area of the flexor digitorum brevis, abductor digiti minimi, and abductor hallucis at baseline, 6 and 12-weeks. Subsequently, participants completed an unexpected gait termination protocol (12 of 50 trials unexpected) and average electromyography magnitude was recorded., Findings: After 12-weeks the orthotic group cross-sectional area significantly decreased by 9.6% (P < .001) for the flexor digitorum brevis, 17.1% for abductor digiti minimi (P < .001) and 17.4% for abductor hallucis (P < .001). There were no significant differences of muscle activity magnitude for the intrinsic muscles., Interpretation: The short-term use of custom-made foot orthoses created a decrease in muscle size of the flexor digitorium brevis, abductor digiti minimi and abductor hallucis plantar intrinsic muscles but had no effect on muscle activity. Clinically, these results help to understand the adaptations that are created when foot orthoses are supporting a pes planus foot structure when reducing plantar pressures. These findings may help enhance the prescription of foot orthoses by adding a strength program to prevent disuse atrophy of these muscles., Competing Interests: Declaration of Competing Interest The authors declare that there are no financial or personal conflict of interests., (Copyright © 2020 Elsevier Ltd. All rights reserved.)

Background: Flat-foot involves total collapse of medial longitudinal arch, which becomes distressful when children begin to stand on their feet. Flat foot is usually diagnosed on clinical examination, however due to lack of a standardized protocol, there are conflicting views regarding its management. The objective of this study is to determine the accuracy of radiographic and podometric measurements in diagnosing paediatric flat foot., Methods: It was a cross sectional diagnostic accuracy study. Eighty-four children of preschool and school going age were recruited equally into control and flat foot groups. Each child was examined clinically and was further classified into having flexible or rigid flat foot. For radiographic assessment, lateral and anteroposterior foot radiographs were taken while footprints were captured using podoscope and analysed with FREESTEP software. The diagnostic accuracy and correlation among different parameters were also computed., Results: Clinically, of the 42 children in the flat foot group, 26 had flexible while 16 had rigid flat foot. Of these, 40 children were flat footed on one or more radiographic parameters, while 36 had podometric measurements within the flat foot range. Radiography had the sensitivity and specificity of 95% and 69%, respectively, while podometry was 86% sensitive and 47% specific. Clark's angle had highest sensitivity of 90%, with AUC of 0.952. A strong positive correlation was found between arch index and talocalcaneal angle (r=.805)., Conclusions: The diagnostic accuracy of radiography was more than podometry. More specific and sensitive parameters in combination with clinical assessment may prove to be useful in the management of paediatric flat foot.

Flatfoot is a common deformity in the pediatric population and has a multitude of causes. Sometimes, it can be a normal finding in children, and treatment should not be guided only based on the appearance, but rather after thoroughly assessing the patient and the impact it has on the child's daily life. In this paper, we describe the quality of life that the patients are experiencing after the surgical treatment of this pathology. We made a comparison between the most used techniques for correcting flatfoot and insisted on the postoperative comfort of the patient, rehabilitation, and the time it took to get back to their daily routine. The comparison was made between Mosca calcaneal lengthening osteotomy, Grice extraarticular arthrodesis, arthroereisis and triple arthrodesis of the foot. All of the surgeries were performed by the same doctor at "Grigore Alexandrescu" Emergency Hospital for Children in Bucharest. From the data collected, we propose that newer, minimally invasive techniques could be used in treating this pathology in order to help the patient feel better in the postoperative period and avoid some of the complications regularly encountered when using the old techniques., (©Carol Davila University Press.)

Background: The tibialis posterior tendon (TPT) is the main dynamic stabilizer of the medial longitudinal arch of the foot. Especially in adult acquired flatfoot deformity (AAFD) the TPT plays a detrimental role. The pathology and function of the tendon have been extensively investigated, but knowledge of its insertional anatomy is paramount for surgical procedures. This study aimed to analyze the complex distal footprint anatomy of the TPT., Methods: Forty-one human anatomical specimens were dissected and the distal TPT was followed to its bony footprints. After tendon removal the footprints were marked with ink. Standardized photographs were taken and consecutively analyzed by digital imaging measurements. Footprint length, width, area of insertion, location, and shape was studied regarding the main insertion at the navicular bone., Results: All specimens had the main TPT insertion at the navicular bone (41/41, 100%). Sixty-three percent of navicular TPT insertions were located at the plantar aspect. The mean navicular footprint measured 12.1 mm × 6.9 mm in length and width, respectively. The tendon further spread into several slips which anchored the tibialis posterior deep in the plantar arch. TPT insertions were highly variable with an involvement of up to eight distinct bony footprints in the mid- and hindfoot. The second most common additional footprint was the lateral cuneiform (93% of dissected feet), followed by the medial cuneiform (80%), the metatarsal bases [1-5] (80%), the cuboid (46%), the intermediate cuneiform (19%), and the calcaneus (12%)., Conclusions: The present study adds to current knowledge on the footprint anatomy of the TPT. Based on the findings of this study we advocate a plantar location of flexor digitorum longus tendon transfer in flexible AAFD in order to restore the anatomical lever and insertion of the TPT.

Hallux valgus is one of the most common and painful deformities, occurring due to adductor/abductor imbalance of the big toe. Many structural foot disorders have been suggested as the cause of hallux valgus deformity. In this study, we aimed to show the relationship between hallux valgus and pes planus in adult males. A total of 213 patients were included in this study between May 2013 and May 2014. 54 patients with hallux valgus angle (HVA) >20° and intermetatarsal angle (IMA) >9° were evaluated in the case group and 159 patients randomly selected from those admitted for a recent foot ankle trauma with the HVA <15° and IMA <9° were the control group. All patients' HVA, IMA, and talonavicular coverage angle on anteroposterior (AP) foot radiographs and talar-first metatarsal angle (Meary's angle), calcaneal pitch angle, and lateral talocalcaneal angle on lateral foot radiographs were measured. There was no significant difference in talonavicular and Meary's angles between the groups. Calcaneal pitch angle was significantly lower in the case group, whereas talonavicular angle was higher in the control group. Calcaneal pitch angle and lateral talocalcaneal angle showed significant negative correlation with HVA and IMA. There are few reports in the literature about the relationship between pes planus and hallux valgus. Our results strongly showed a high correlation between pes planus and hallux valgus. Further larger patient cohort studies are needed to support our results., (Copyright © 2019 the American College of Foot and Ankle Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: The prevalence of foot pathologies, such as flatfoot deformity and hallux valgus, is higher in women and increases with age. It has been reported that these types of foot disorders may also be linked to excessive mobility of the subtalar joint to the eversion direction during weight bearing. Given that the mobility of the joint is determined by its articular morphology, sex- and age-related variations in the subtalar articular surface morphology are possible. The purpose of this study was to investigate the orientation and the curvature radii of the talar articular facets of the calcaneus in relation to age and sex using three-dimensional computer tomography., Methods: Fifty-six feet without subtalar injuries or disorders were included in this study. The orientations of the talar articular surfaces of the calcaneus were quantified in the sagittal and coronal planes. The curvature radii of the articular surfaces of the calcaneus were also assessed based on the approximations of the sphere surfaces., Results: The talar articular surface was oriented more anteriorly and medially in the females than in the males. The curvature radius of the calcaneal posterior facet in the females exhibited a positive correlation with age, indicative of increased articular surface flattening., Conclusions: The morphological features of the female calcaneus could induce excessive eversion and could lead to a higher prevalence of foot disorders, including flatfoot and hallux valgus, in elderly females. This study contributes to an understanding of the sexual dimorphism of the articular surfaces of the calcaneus and provides insight into the mechanisms that underline various foot disorders., (Copyright © 2020 Elsevier GmbH. All rights reserved.)

Objective: A distinctive feature of the modern human foot is the presence of a medial longitudinal arch when weight-bearing. Although the talus and calcaneus play a major role in the structure and function of the human foot, the association between the morphology of these bones and longitudinal arch height has not been fully investigated. A better understanding of this relationship may assist in the interpretation of pedal remains of fossil hominins, where features of the foot and ankle morphology have been described as providing evidence for the presence of a longitudinal arch., Methods: For this study, weight-bearing radiographs of 103 patients from an urban US Level 1 trauma center, taken as part of a clinical examination for medical evaluation, were selected. These radiographs were classified as to foot type by arch height as defined using the calcaneal inclination angle. From this group, 68 radiographs were suitable for linear and angular measurements of the talus and 74 of the calcaneus. The relationships between these measurements and arch height were explored using least squared linear regression analysis., Results: The results demonstrate that angular measurements of the calcaneus (particularly those that reflect the relationship of the talar articular facets to each other and the tilt of the calcaneocuboid joint to the longitudinal axis of the calcaneus) are predictive of arch height (r 2 = .29-.44 p ≤ .001). All angular measurements of the talus and all examined linear measurements of both the talus and calcaneus were not predictive of arch height., Discussion: These results suggest that certain angular measurements of the calcaneus are associated with arch height in the modern human foot. While this information is useful in the interpretation of hominin pedal remains, the relationship of the morphology of these bones, as well as other bones of the foot, to arch height is complex, requiring further investigation., (© 2020 Wiley Periodicals, Inc.)

Reconstruction of the flexible adult-acquired flatfoot deformity (AAFD) is controversial, and numerous procedures are frequently used in combination, including flexor digitorum longus transfer, medializing calcaneal osteotomy (MCO), heel cord lengthening/gastrocnemius recession, lateral column lengthening (LCL), Cotton osteotomy or first tarsometatarsal fusion, and spring ligament reconstruction. This article summarizes recent studies demonstrating that patients have significant improvements after operative treatment of flexible AAFD. It reviews current literature on clinical and radiographic outcomes of the MCO, LCL, and Cotton osteotomies. The authors describe how this information can be used in surgical decision making in order to tailor operative treatment to an individual patient's deformity., (Copyright © 2019 Elsevier Inc. All rights reserved.)

The collection of 1550 Homo naledi fossil remains includes six tarsal and five metatarsal bones from the right foot, forming a nearly complete humanlike flat foot arch. The missing right medial cuneiform, however, raises our interest to explore the true structure of Homo naledi 's foot arch. We hypothesize that Homo naledi does not have flat foot. To verify our hypothesis, the left medial cuneiform of Homo naledi was mirrored using three-dimensional reconstruction and virtual model analysis. Then, we defined quantities of Euler, standardized the body coordinate system of foot bone and developed a new foot arch reconstruction method based on discrete bones. The reconstructed transverse foot arch corroborated our hypothesis, thus providing biomechanical evidence for interpreting the evolution of human locomotion and bringing novel ideas to the research of the biomechanical mechanism of ankle stability.

Background: The spring ligament fibrocartilage complex (SLFC) is an important static foot stabilizer comprising the superomedial ligament (SML) and the inferior ligament, with anatomical variations (third ligament). The aim of this study was to describe the patterns of the lesions found during SLFC surgery, to allow direct comparison between the results with various surgical techniques., Methods: Fourteen consecutive patients with SLFC lesions were analyzed during surgical treatment. The mean patient age was 37.3 years, and the mean time from injury was 6.9 months. Intraoperative assessments and anatomical descriptions of the lesions were collected., Results: Three types of lesion were found. In 13 of 14 cases, only the superomedial ligament was involved: five superomedial ligament distentions and eight superomedial ligament ruptures. In one case, total SLFC (superomedial and inferior ligaments) rupture was observed., Conclusions: The first classification of SLFC lesions is presented, which is simple, consistent, and based on anatomical description.

Background/aim: Changes in balance and postural control have been reported during the perimenopausal period. We investigated the effect of medial longitudinal arch height and medial arch support insoles on postural sway and balance in middle-aged perimenopausal women., Materials and Methods: 29 women with normal arches and 29 women with low arches were included in the study. The foot arches of the participants were determined using the arch height index. The static balance index (SBI) measured by Kinesthetic Ability Trainer 3000 and functional reach test were used to evaluate postural balance. Measurements were obtained from all participants with and without medial arch support insoles., Results: The SBI-total scores without the insoles were found to be significantly higher in the lower arch group than in the normal arch group. SBI-total, SBI-anteroposterior, and SBI-mediolateral scores significantly improved in the low arch group in the presence of insoles, whereas the usage of insoles resulted in no difference in the normal arch group. In the presence of insoles, the reach distances to left and right sides increased in both groups, while the forward functional reach distances decreased., Conclusion: Medial longitudinal arch height and medial arch support insoles affect the balance parameters in perimenopausal women., (This work is licensed under a Creative Commons Attribution 4.0 International License.)

Background:: Lateral column lengthening and plantarflexion dorsal opening wedge osteotomy of the medial cuneiform are 2 commonly used procedures to address the deformity seen in severe flexible pes planovalgus deformity. Traditionally, iliac crest allograft or autograft has been used to fill the osteotomy sites. Porous metallic wedges can be used as an alternative to avoid the concerns associated with both autograft and allograft., Methods:: We performed a retrospective review of patients who had corrective osteotomies utilizing metallic wedges to address flexible pes planovalgus with at least 2 years of follow-up data. Preoperative radiographic measurements (anteroposterior [AP] and talo-first metatarsal angle, calcaneal pitch, talocalcaneal angle, and talonavicular uncoverage angle) and functional scores (visual analog scale [VAS] pain, Foot and Ankle Ability Measure [FAAM] Activities of Daily Living [ADL], FAAM Sports) were compared to postoperative radiographic measurements and functional scores., Results:: There were statistically significant improvements in all radiographic parameters and functional scores. Two nonunions were seen, one of which healed with revision surgery while the other was asymptomatic. At the time of last radiographic follow-up, there were no recurrences of deformity or collapse., Conclusion:: Porous metallic wedges offer an attractive alternative to autograft and/or allograft in the setting of corrective osteotomies for severe flexible pes planovalgus. Patients who underwent corrective osteotomies using these wedges demonstrated reliable, effective, and stable radiographic correction as well as significant improvements in function and pain., Level of Evidence:: Level IV, case series.

Adult acquired flatfoot deformity (AAFD) is a pathology with a wide range of treatment options. Physicians decide the best treatment based on their experience, so the process is entirely subjective. A better understanding of soft tissue stress and its contribution in supporting the plantar arch could help to guide the clinical decision. Traditional experimental trials cannot consistently evaluate the contribution of each tissue. Therefore, in this research a 3-Dimensional FE foot model was reconstructed from a normal patient in order to measure the stress of the passive stabilizers of the arch, and its variation in different scenarios related with intermediate stages of AAFD development. All bones, the plantar fascia (PF), cartilages, plantar ligaments and the spring ligament (SL) were included, respecting their anatomical distribution and biomechanical characteristics. An AAFD evaluation scenario was simulated. The relative contribution of each tissue was obtained comparing each result with a normal case. The results show that PF is the main tissue that prevents the arch elongation, while SL mainly reduces the foot pronation. Long and short plantar ligaments play a secondary role in this process. The stress increment on both PF and SL when one of two fails suggests that these tissues complement each other. These findings support the theory that regards the tibialis posterior tendon as a secondary actor in the arch maintenance, compared with the PF and the SL, because this tendon is overstretched by the hindfoot pronation around the talonavicular joint. This approach could help to improve the understanding of AAFD., (Copyright © 2019 Elsevier Ltd. All rights reserved.)

Background: Prevalence of pathological flatfoot has not been well defined in the literature. The objective of this study was to establish the prevalence of pathological flatfoot in school-age children and investigate the factors associated with this deformity., Methods: A total of 667 children (327 girls and 340 boys) were recruited for this cross-sectional study with multi-stage clustered random sampling. The diagnosis of flatfoot was based on clinical observations and measurements using a suggested systematic protocol. Pathological flatfoot in this study did not merely screen for structural flatfoot, it included symptomatic conditions as well as musculoskeletal risk factors predisposing a progressive flatfoot in children., Results: Prevalence of pathological flatfoot was 10.3% in children aged 7-14 years, but this prevalence decreased with age. There was no difference in prevalence of pathological flatfoot between the genders. Children with high BMI were more likely to have pathological flatfoot. Heel valgus (r=0.1; p=0.01) and dorsiflexion range (r=0.14; p<0.001) were both significantly associated with the presence of pathological flatfoot in children; but with only small correlations., Conclusions: Pathological flatfoot was a prevalent condition in school-age children in Iran. Forty six percent of the flatfeet observed in school-age children were classified as pathological., (Copyright © 2018 Elsevier Ltd. All rights reserved.)

Objective: The unique foot morphology and distinctive functions facilitate complex tasks and strategies such as standing, walking, and running. In those weight-bearing activities, postural stability (PS) plays an important role. Correlations among foot type, PS, and other musculoskeletal problems that increase sport injury risk are known. However, long-term associations among the foot type, the PS, and body weight (BW) distribution are lacking. Thus, the purpose of this study was to longitudinally identify changes in foot morphology, PS, and symmetry in BW distribution during adolescence among elite male soccer players., Methods: Thirty-five Czech elite male soccer players (age, 15.49 ± 0.61 years; BW, 64.11 ± 6.16 kg; body height, 174.62 ± 5.71 cm) underwent foot type, PS, and BW distribution measurements during 3 consecutive years (T1, T2, T3). The Chippaux-Smirak index (CSI), BW distribution, and centre of pressure (COP) displacement (total traveled way [TTW]) of each player for the preferred (PL) and non-preferred leg (NL) were acquired. Repeated-measures analysis of variance (RM ANOVA), Bonferroni´s post hoc tests, and partial eta-squared (ηp2) coefficient were used for investigating the effect of time on selected variables and effect size evaluation., Results: Statistically significant effect of time on CSI values (PL: F2,68 = 5.08, p < 0.01, ηp2 = 0.13 and NL: F2,68 = 10.87, p < 0.01, ηp2 = 0.24) and COP displacement values (PL: F2,68 = 5.07, p <0.01, ηp2 = 0.13; NL: F2,68 = 3.53, p <0.05, ηp2 = 0.09) for both legs over 3-years period was identified. Furthermore, the Bonferroni´s post hoc analysis revealed a significant improvement of PS values in the PL (TTWT1 = 1617.11 ± 520.22 mm vs. TTWT2 = 1405.29 ± 462.76, p < 0.05; and between TTWT1 = 1617.11 ± 520.22 mm vs. TTWT3 = 1370.46 ± 373.94, p < 0.05). Only BW distribution parameter showed no significant differences, although slightly improved over time., Conclusions: We observed changes in foot typology, PS, and BW distribution in young elite male soccer players during 3 consecutive years. Results demonstrated that changes in PS and body weight distribution under the high-load sport conditions during adolescence may improve with aging, except for foot morphology. Therefore, foot morphology should be carefully monitored to minimize sport injury risk in professional young soccer players during adolescence. Further research is necessary to determine more clear associations between these parameters, soccer-related injuries, and sport performances., Competing Interests: The authors have declared that no competing interests exist.

Background: Previous work has demonstrated that the amount of radiographic hindfoot correction required at the time of adult-acquired flatfoot deformity (AAFD) operative treatment can be predicted by the amount of radiographic deformity present before surgery. Successful outcomes after reconstruction are closely correlated with hindfoot valgus correction. However, it is not clear if differences exist between clinical and radiographic assessment of hindfoot valgus. The purpose of this study was to evaluate the correlation between radiographic and clinical evaluation of hindfoot alignment in patients with stage II AAFD., Methods: Twenty-nine patients (30 feet) with stage II AAFD, 17 men and 12 women, mean age of 51 (range, 20-71) years, were prospectively recruited. In a controlled and standardized fashion, bilateral weightbearing radiographic hindfoot alignment views were taken. Radiographic parameters were measured by 2 blinded and independent readers: hindfoot alignment angle (HAA) and hindfoot moment arm (HMA). Clinical photographs of hindfoot alignment were taken in 3 different vertical camera angulations (0, 20, and 40 degrees). Pictures were assessed by the same readers for standing tibiocalcaneal angle (STCA) and resting calcaneal stance position (RCSP). Intra- and interobserver reliability were assessed by Pearson/Spearman's and intraclass correlation coefficient (ICC), respectively. Relationship between clinical and radiographic hindfoot alignment was evaluated by a linear regression model. Comparison between the different angles (RCSP, STCA, and HAA) was performed using the Wilcoxon rank-sum test. P values of less than .05 were considered significant., Results: We found overall almost perfect intraobserver (range, 0.91-0.99) and interobserver reliability (range, 0.74-0.98) for all measures. Mean value and confidence interval (CI) for RCSP and STCA were 10.8 degrees (CI, 10.1-11.5) and 12.6 degrees (CI, 11.7-13.4), respectively. The position of the camera did not influence readings of clinical alignment ( P > .05). The mean HMA was 18.7 mm (CI, 16.3-21.1 mm), and the mean HAA was 23.5 degrees (CI, 21.1-26.0). Clinical and radiographic hindfoot alignment were found to significantly correlate ( P < .05). However, the radiographic HAA demonstrated increased valgus compared to both clinical alignment measurements, with a mean difference of 12.8 degrees from the RCSP (CI, 11.0-14.5, P < .0001) and 11.0 degrees from the STCA (CI, 9.2-12.8, P < .0001)., Conclusion: We found significant correlation between radiographic and clinical hindfoot alignment in patients with stage II AAFD. However, radiographic measurements of HAA demonstrated significantly more pronounced valgus alignment than the clinical evaluation. The results of our study suggest that clinical evaluation of hindfoot alignment in patients with AAFD potentially underestimates the bony valgus deformity. One should consider these findings when using clinical evaluation in the treatment algorithm of flatfoot patients., Level of Evidence: Level II, prospective comparative study.

Purpose: Many musculoskeletal disorders are associated with over-pronated foot and decreased medial longitudinal arch (MLA) height. Foot intrinsic muscles and plantar fascia (PF) are the primary structures that support MLA. An important reason for the over-pronated foot and the reduction in the MLA height may be the morphological characteristics of the foot intrinsic muscles and PF as well as changes in their mechanical properties. The aim of the present study is to investigate the morphologic structure and mechanical properties of PF, flexor hallucis brevis (FHB), flexor digitorum brevis (FDB), and abductor hallucis (AbH) muscles in individuals with flat foot and to compare the results with those of healthy individuals., Methods: The study included 80 participants, 40 with flat foot and 40 with normal foot posture. The foot posture of the participants was assessed using the Foot Posture Index. PF, FHB, FDB, and AbH thickness and stiffness were measured with an ultrasonography device using a linear ultrasonography probe., Results: Individuals with flat foot had higher AbH thickness compared to individuals with normal foot posture ( p < 0.001), whereas both groups were similar in terms of PF ( p = 0.188), FHB ( p = 0.627), and FDB ( p = 0.212) thickness. Stiffness values of the assessed tissues were similar in both groups ( p > 0.05)., Conclusion: AbH thickness was higher in individuals with flat foot; however, PF, FHB, and FDB thickness were similar in both groups. In addition, our results suggest that foot posture is not related to the stiffness of the assessed tissues.

Nowadays, excessive body weight is the cause of death of more people than malnutrition. Obesity is a growing health problem worldwide, which also results in a considerable number of movement dysfunctions, including degenerative changes and foot pain. The study aimed to assess the effect of overweight and obesity on the height of foot arches in females aged 10-84 years, as well as to establish which factor - age or BMI - affected the height of medial longitudinal arch (MLA) to a greater extent. Three groups of females (96 pupils, 86 young adults and 88 seniors) were selected to participate in the study. The participants' height and weight were measured, their BMI calculated and their body weight status categorized as normal weight, overweight or obesity. The height of foot arches was assessed using the Arch Index (AI). According to the value of the AI, the foot was defined as high-arched, normal or flat. Differences in participants' AI were determined in their age and weight status groups. Correlations between BMI and AI were calculated for the whole study sample and age groups. The analysis used the Shapiro-Wilk test, the Kruskal-Wallis test and Pearson's linear correlation. Overweight or obesity prevailed in 31% of pupils, 4.7% of young adults and in 77% of seniors. Pupils and young adults had often the high-arched foot. Flat feet were mostly observed in seniors and were common in obese individuals. BMI significantly correlated with the height of the foot arch but their age did not. Excessive body weight contributes to the development of flat feet to a greater extent than age., (Copyright © 2018 Elsevier GmbH. All rights reserved.)

Background and Objective: Flatfeet can be evaluated by measuring the calcaneal-fifth metatarsal angle on a weight-bearing lateral foot radiograph. This study aimed to develop an automated method for determining the calcaneal-fifth metatarsal angle on weight-bearing lateral foot radiograph., Method: The proposed method comprises four processing steps: (1) identification of the regions including the calcaneus and fifth metatarsal bones in a foot image; (2) delineation of the contours of the calcaneus and the fifth metatarsal; (3) determination of the tangential lines of the two bones from the contours; and (4) determination of the calcaneal-fifth metatarsal angle between the two tangential lines as arch angle., Results: The proposed method was evaluated using 300 weight-bearing lateral foot radiographs. The arch angles determined by the proposed method were compared with those measured by a radiologist, and the errors between the automatically and manually determined angles were used to evaluate the precision of the method. The average error in the proposed method was found to be 1.12° ± 1.57° In the study, in 73.33% of the cases, the arch angles could be determined automatically without redrawing any tangential lines; in 23.00% of the cases, the angles would be correctly determined by redrawing one of the tangential lines; further, in only 3.67% of the cases, both the calcaneal and fifth metatarsal tangential lines needed to be redrawn to determine the arch angles., Conclusion: The results revealed that the proposed method has potential for assisting doctors in measuring the arch angles on weight-bearing lateral foot radiographs more efficiently., (Copyright © 2017 Elsevier B.V. All rights reserved.)

Objective: To investigate the correlation between MRI, clinical tests, histopathologic features of posterior tibial tendon (PTT) dysfunction in patients with acquired adult flatfoot deformity surgically treated with medializing calcaneal osteotomy and flexor digitorum longus tendon transposition., Materials and Methods: Nineteen patients (11 females; age: 46 ± 15 year, range 18-75) were pre-operatively evaluated using the single heel rise (HR) and the first metatarsal rise (FMR) sign tests. Two reviewers graded the PTT tears on a I-III scale and measured the hindfoot valgus angle on the pre-operative MRI of the ankle. The specimens of the removed portion of PTT were histologically analysed by two pathologists using the Bonar and Movin score. Linear regression, Spearman's rank-order, and intraclass correlation coefficient (ICC) statistics were used., Results: ICC for MRI was excellent (0.952). Correlation between FMR and HR tests was at limit of significance (r = 0.454; P = 0.051). The HR and FMR tests were significantly correlated to the Movin score (r = 0.581; P = 0.009 and r = 0.538; P = 0.018, respectively) and were not significantly correlated to the Bonar score (both with a r = 0.424; P = 0.070). PTT tendinopathy grading at MRI was significantly correlated to the FMR test (p = 0.041) but not to the hindfoot valgus angle (p = 0.496), the HR test (p = 0.943), the Bonar score (p = 0.937), and the Movin score (p = 0.436). The hindfoot angle was not correlated to any of the other variables (p > 0.264)., Conclusion: For PTT dysfunction, there is high correlation between HR and FMR test and histology evaluated using the Movin score, while no correlation was seen for the Bonar score. Semiquantitative grading of PTT dysfunction at MRI only correlates to the FMR and not to histology. The hindfoot valgus angle is not correlated to any of the considered variables., (Copyright © 2017 Elsevier B.V. All rights reserved.)

A recent systematic review of measures of foot development used the medial longitudinal arch profile as its primary indicator of development. A comparative analysis of existing studies was undertaken. This work confirmed changes with arch profile were age-dependent, although the age at which foot development ceased remains unknown. This work also highlighted the abundance of clinical measures used in existing research and outlined the challenges with drawing consensus from available data. There is a clear need to move this debate forward and, to do so, it is essential that scientific and clinical communities unite. It is time to abandon ill-defined measures of foot position, look beyond the medial longitudinal arch as a sole parameter of foot development and re-focus our perspective(s) on the paediatric foot in order to make advances with clinical practice and research.

Deltoid ligament reconstruction allows for joint preservation of the ankle in the setting of patients a triple arthrodesis due to a flat foot deformity. Although the increased forces that may occur in the ankle joint after a triple arthrodesis cannot be eliminated, reconstruction of the ligament will delay and may prevent the onset arthritis, allowing the patient to maintain mobility of the ankle joint. The anatomy, surgery, and risks and benefits are discussed., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Aim: The aim of this study was to investigate the intratester reliability of digital photographic method for quantifying static lower extremity alignment in individuals with flatfeet and normal feet types., Methods: Thirteen females with flexible flatfeet and nine females with normal feet types were recruited from university communities. Reflective markers were attached over the participant's body landmarks. Frontal and sagittal plane photographs were taken while the participants were in a standardized standing position. The markers were removed and after 30 min the same procedure was repeated. Pelvic angle, quadriceps angle, tibiofemoral angle, genu recurvatum, femur length and tibia length were measured from photographs using the Image j software., Results: All measured variables demonstrated good to excellent intratester reliability using digital photography in both flatfeet (ICC: 0.79-0.93) and normal feet type (ICC: 0.84-0.97) groups., Conclusion: The findings of the current study indicate that digital photography is a highly reliable method of measurement for assessing lower extremity alignment in both flatfeet and normal feet type groups., (Copyright © 2016. Published by Elsevier Ltd.)

Purpose . To investigate the effect of cuboid osteotomy lateral column lengthening (LCL) for the correction of stage II B adult-acquired flatfoot deformity in cadaver. Methods . Six cadaver specimens were loaded to 350 N. Flatfoot models were established and each was evaluated radiographically and pedobarographically in the following conditions: (1) intact foot, (2) flatfoot, and (3) cuboid osteotomy LCL (2, 3, 4, and 5 mm). Results . Compared with the flatfoot model, the LCLs showed significant correction of talonavicular coverage on anteroposterior radiographs and talus-first metatarsal angle on both anteroposterior and lateral radiographs ( p < .05). Compared with the intact foot, the above angles of the LCLs showed no significant difference except the 2 mm LCL. In terms of forefoot pressure, medial pressure of the 2 mm LCL ( p = .044) and lateral pressure of the 3, 4, and 5 mm LCLs showed statistical differences ( p < .05), but lateral pressure of the 3 mm LCL was not more than the intact foot as compared to the 4 and 5 mm LCLs, which was less than medial pressure. Conclusion . Cuboid osteotomy LCL procedure avoids damage to subtalar joint and has a good effect on correction of stage II B adult-acquired flatfoot deformity with a 3 mm lengthening in cadavers.

Background: The aim of this study was to determine the level of agreement between common clinical foot classification measures., Methods: Static foot assessment was undertaken using the Foot Posture Index (FPI-6), rearfoot angle (RFA), medial longitudinal arch angle (MLAA) and navicular drop (ND) in 30 participants (29 ± 6 years, 1.72 ± 0.08 m, 75 ± 18 kg). The right foot was measured on two occasions by one rater within the same test environment. Agreement between the test sessions was initially determined for each measure using the Weighted Kappa. Agreement between the measures was determined using Fleiss Kappa., Results: Foot classification across the two test occasions was almost perfect for MLAA (Kw = .92) and FPI-6 (Kw = .92), moderate for RFA (Kw = .60) and fair for ND (Kw = .40) for comparison within the measures. Overall agreement between the measures for foot classification was moderate (Kf = .58)., Conclusion: The findings reported in this study highlight discrepancies between the chosen foot classification measures. The FPI-6 was a reliable multi-planar measure whereas navicular drop emerged as an unreliable measure with only fair agreement across test sessions. The use of this measure for foot assessment is discouraged. The lack of strong consensus between measures for foot classification underpins the need for a consensus on appropriate clinical measures of foot structure.

Background: Underlying bony deformity may be related to development of adult-acquired flatfoot deformity (AAFD). Multiplanar weightbearing (MP-WB) computed tomography can be used to identify subtalar deformity which may contribute to valgus hindfoot alignment. On coronal MP-WB images, 2 angles reliably evaluate the subtalar joint axis: the angle between the inferior facet of the talus and the horizontal (inftal-hor) and the angle between the inferior and superior facets of the talus (inftal-suptal). Although these angles have been shown to differ significantly between flatfoot patients and controls, no study has investigated their relationships with other components of AAFD. We hypothesized that these angles would correlate strongly with commonly used radiographic measures of AAFD., Methods: Forty-five patients with stage II AAFD and 17 control patients underwent MP-WB imaging and standard weightbearing radiographs. MP-WB measurements were correlated with standard radiographic measurements of AAFD. Differences between AAFD and control patients were assessed using independent samples t tests and Mann-Whitney U tests. To assess correlations between each MP-WB measurement and radiographic measurement, factorial generalized linear models (GLMs) were constructed., Results: Patients with AAFD differed from the controls in all measured angles (P ≤ .001 for each). After accounting for differences between flatfoot and control patients, inftal-hor was not significantly correlated with any of the radiographic angles. Inftal-suptal, however, correlated with the AP coverage angle, AP talar-first metatarsal angle, calcaneal pitch, Meary's angle, medial column height, and hindfoot alignment after accounting for differences between flatfoot patients and controls. Meary's angle alone explained 48% of the variation in inftal-suptal angles., Conclusion: As measured on coronal MP-WB images, patients with stage II AAFD had more innate valgus in their talar anatomy as well as more valgus alignment of their subtalar joints than did control patients. It is possible that this information could be used to identify patients likely to have progression of deformity and may ultimately guide the approach to operative reconstruction., Level of Evidence: Level III, case-control study., (© The Author(s) 2016.)

Background: The Cotton osteotomy has been used to correct residual forefoot supination in flexible flatfoot deformity reconstruction. The purpose of this study was to delineate the radiographic effects of the Cotton osteotomy by controlling for concomitant procedures used for deformity correction., Methods: We retrospectively analyzed 67 patients who underwent a Cotton osteotomy as part of a flatfoot reconstructive procedure. We evaluated 12 radiographic parameters including the articular surface angles of the foot, Meary angle, and a newly defined medial arch sag angle (MASA). Twenty-eight of these patients were matched to a cohort that did not undergo a Cotton osteotomy., Results: In all patients who underwent a Cotton osteotomy, there were statistically significant changes in the articular surface angles and medial arch height (P < .05). No radiographic secondary sag of the medial column was seen at final follow-up. Compared to 28 matched controls, the Cotton osteotomy did not improve Meary angle but provided an additional 6.5 degrees correction of the MASA (P = .002). After reliability testing, the intraclass correlation coefficient was found to be substantial for the MASA compared to Meary angle., Discussion: The data suggest that the MASA was a useful radiographic tool for assessing midfoot collapse in the setting of pes planovalgus. The current study demonstrated the corrective capacity of the Cotton osteotomy on the MASA; at final follow-up, there was no evidence of radiographic instability. This is suggestive that a naviculocuneiform arthrodesis may not be warranted for medial column stabilization in the setting of flatfoot reconstruction., Level of Evidence: Level III, case control study., (© The Author(s) 2015.)

Background: Deletions of the HOXC gene cluster result in variable phenotypes in mice, but have been rarely described in humans., Objective: To report chromosome 12q13.13 microdeletions ranging from 13 to 175 kb and involving the 5' HOXC genes in four families, segregating congenital lower limb malformations, including clubfoot, vertical talus and hip dysplasia., Methods: Probands (N=253) with clubfoot or vertical talus were screened for point mutations and copy number variants using multiplexed direct genomic selection, a pooled BAC targeted capture approach. SNP genotyping included 1178 probands with clubfoot or vertical talus and 1775 controls., Results: The microdeletions share a minimal non-coding region overlap upstream of HOXC13, with variable phenotypes depending upon HOXC13, HOXC12 or the HOTAIR lncRNA inclusion. SNP analysis revealed HOXC11 p.Ser191Phe segregating with clubfoot in a small family and enrichment of HOXC12 p.Asn176Lys in patients with clubfoot or vertical talus (rs189468720, p=0.0057, OR=3.8). Defects in limb morphogenesis include shortened and overlapping toes, as well as peroneus muscle hypoplasia. Finally, HOXC and HOXD gene expression is reduced in fibroblasts from a patient with a 5' HOXC deletion, consistent with previous studies demonstrating that dosage of lncRNAs alters expression of HOXD genes in trans., Conclusions: Because HOXD10 has been implicated in the aetiology of congenital vertical talus, variation in its expression may contribute to the lower limb phenotypes occurring with 5' HOXC microdeletions. Identification of 5' HOXC microdeletions highlights the importance of transcriptional regulators in the aetiology of severe lower limb malformations and will improve their diagnosis and management., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/)

Objective: The aims of this study were to measure the distal femoral cartilage thicknesses of patients with pes planus by using ultrasound imaging and to explore whether ultrasound measurements are associated with degree of pes planus., Design: One hundred seven patients (61 men, 46 women; aged 18-45 yrs) with pes planus and 107 age- and sex-matched as well as body mass index-matched healthy controls were enrolled in this study. After clinical assessment of the patients, measurements for pes planus were done on the radiographs, and ultrasound imaging of the distal femoral cartilage was performed from the right medial condyle, the right lateral condyle, the right intercondylar area, the left medial condyle, the left lateral condyle, and the left intercondylar area., Results: Femoral cartilage values were thicker than those of the control group at all measurement sites (except for the right lateral condyle) (P's < 0.05). In a subgroup analysis regarding the sex difference, right medial condyle and left medial condyle values in the male subjects as well as right lateral condyle, right intercondylar area, left lateral condyle, and left intercondylar area values in the female subjects were found to be thicker (all P < 0.05)., Conclusions: The distal femoral cartilages of the pes planus patients seem to be thicker, and this finding could possibly stem from excessive mechanical stress on the knee joint caused by impaired lower extremity biomechanics.

Objective: To investigate the effects of a foot-muscle trainingprogram on plantarpressure distribution, foot muscle strength, and foot function in persons with flexible flatfoot., Material and Method: Participants received foot-muscle training 3 times weekly, over 8 weeks. Training consisted of gastrosolues muscle stretching and strengthening the muscles around the ankle and the intrinsic muscles. The contact area andpeak pressure under the hallux, first metatarsal, and medial midfoot were assessed by the Force Distribution Measurement Plaform while walking. Strength ofthe tibialis posterior and peroneus longus muscles were assessed by handheld dynamometer. Foot function regarding difficulty in activities of daily living was assessed. All measures were assessed at pre-training, intermediate-training, and post-training. Friedman ANOVA was used for testing mean differences among the variables., Results: Five participants with flexible flatfoot were recruited in the study. Results demonstrated significant increases in tibialis posterior (p = 0.018) and peroneus longus muscles strength (p = 0.007), and significant decrease infootfunction score (p = 0.021). In addition, no significant difference in contact area and peak pressure was observed among testing periods., Conclusion: Foot-muscle strength and foot function in persons with flexible flatfoot can be improved significantly after receiving foot-muscle training.

Background: Flexible flat foot is described as a reduction in the height of the medial longitudinal arch and may occur from abnormal foot pronation. A foot orthosis is thought to modify and control excessive pronation and improve arch height., Objective: To compare the immediate effect of three types of orthoses on foot mobility and the arch height index in subjects with flexible flat feet., Study Design: A quasi-experimental study., Method: The dorsal arch height, midfoot width, foot mobility and arch height index were assessed in 20 participants with flexible flat feet (mean age = 23.2 ± 3 years) for three different foot orthosis conditions: soft, semi-rigid and rigid University of California Biomechanics Laboratory (UCBL)., Results: Maximum midfoot width at 90% with arch mobility in the coronal plane was shown in the semi-rigid orthosis condition. The semi-rigid orthosis resulted in the highest mean foot mobility in 90% of weight bearing, and the rigid orthosis (UCBL) had the lowest mean foot mobility. The soft orthosis resulted in foot mobility between that of the rigid and the semi-rigid orthosis. UCBL orthosis showed the highest arch height index, and the semi-rigid orthosis showed the lowest mean arch height index., Conclusion: Due to its rigid structure and long medial-lateral walls, the UCBL orthosis appears to limit foot mobility. Therefore, it is necessary to make an orthosis that facilitates foot mobility in the normal range of the foot arch. Future studies should address the dynamic mobility of the foot with using various types of foot orthoses., Clinical Relevance: Although there are many studies focussed on flat foot and the use of foot orthoses, the mechanism of action is still unclear. This study explored foot mobility and the influence of foot orthoses and showed that a more rigid foot orthosis should be selected based on foot mobility., (© The International Society for Prosthetics and Orthotics 2014.)

In children's posture examinations the question often arises whether an X-ray examination is necessary or appropriate. On screening and in other cases when X-ray is contraindicated, alternative-non-invasive-examinations are available. To measure the shapes of the children's spines beside the Spinal Mouse also the Zebris ultrasound-based spine measuring instrument is accessible and nowadays commonly used. The main aim of the study is to determine the shape of the school-age children's spines in the sagittal plane with an alternative, non-invasive, radiation-free measuring method. From the results calculated from the values measured with the ultrasound-based motion analysing system-geared to age and height-the normal range of the values of kyphosis (TK), lordosis (LL) and inclination (TTI and LI) is determined. The subjects were children between the ages of 6 and 15 and between the heights of 120 and 180 cm (530 healthy, 394 with bad posture and 332 with flat feet). They were divided into groups according to their height with 5 cm long intervals. The age within the groups was irrelevant. So it is appropriate to give normal values according to height and not according to age. It was revealed that both in healthy children, in children with bad posture and in those with pes planus in the height groups, there was a significant difference between the values of males and females. On the basis of these results, normal values should be divided according to the gender. The measurement results also showed that in some of the height groups the pes planus and bad posture significantly affected the spinal curvatures.

Background: In children with Down syndrome (DS) hypotonia and ligament laxity are characteristic features which cause a number of orthopaedic issues, such as flat foot. The aim of this study was to determine if children with flat foot are characterised by an accentuated external foot rotation during walking., Method: Fifty-five children with DS and 15 typically developing children recruited as control group were assessed using three-dimensional gait analysis, using an optoelectronic system, force platforms and video recording. Parameters related to foot rotation were identified and calculated and the participants' foot morphology was assessed using the arch index., Results: Data obtained in this study showed that while DS children without flat foot displayed the foot position on the transverse plane globally close to controls during the whole gait cycle, the DS children with flat foot were characterised by higher extra-rotation of the foot in comparison with those without flat foot and controls., Conclusions: Our results suggest that the presence of flatfoot lead the children with DS to extra-rotate their feet more than the children without flat foot. From a clinical point of view, these results could enhance the rehabilitative programmes in DS., (© 2013 MENCAP and International Association of the Scientific Study of Intellectual and Developmental Disabilities and John Wiley & Sons Ltd.)

Adult acquired flatfoot deformity is a progressive disorder with multiple symptoms and degrees of deformity. Stage II adult acquired flatfoot can be divided into stage IIA and IIB based on severity of deformity. Surgical procedures should be chosen based on severity as well as location of the flatfoot deformity. Care must be taken not to overcorrect the flatfoot deformity so as to decrease the possibility of lateral column overload as well as stiffness., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Posterior tibial tendon dysfunction (tendinitis, tendinosis, or rupture) and adult acquired flatfoot deformity can manifest with a wide array of bony and soft tissue abnormalities visible on plain radiographs, ultrasound, and magnetic resonance imaging. Imaging abnormalities include various combinations of malalignment, anatomic variants, and enthesopathic and tendinopathic changes. A thorough understanding of differences between anatomic and pathologic presentations of structures in various imaging modalities is an essential tool for clinical and surgical planning., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Objectives: The purpose of this study was to examine the correlation between the foot arch volume measured from static positions and the plantar pressure distribution during walking., Methods: A total of 27 children, two to six years of age, were included in this study. Measurements of static foot posture were obtained, including navicular height and foot arch volume in sitting and standing positions. Plantar pressure, force and contact areas under ten different regions of the foot were obtained during walking., Results: The foot arch index was correlated (r = 0.32) with the pressure difference under the midfoot during the foot flat phase. The navicular heights and foot arch volumes in sitting and standing positions were correlated with the mean forces and pressures under the first (r = -0.296∼-0.355) and second metatarsals (r = -0.335∼-0.504) and midfoot (r = -0.331∼-0.496) during the stance phase of walking. The contact areas under the foot were correlated with the foot arch parameters, except for the area under the midfoot., Conclusions: The foot arch index measured in a static position could be a functional index to predict the dynamic foot functions when walking. The foot arch is a factor which will influence the pressure distribution under the foot. Children with a lower foot arch demonstrated higher mean pressure and force under the medial forefoot and midfoot, and lower contact areas under the foot, except for the midfoot region. Therefore, children with flatfoot may shift their body weight to a more medial foot position when walking, and could be at a higher risk of soft tissue injury in this area.

Background: In patients with Down syndrome (DS) one of the most common abnormalities is flat foot which can interfere significantly with normal daily activities, such as gait. The aim of this study was to quantitatively assess the relationship between the flat foot and the gait alterations in DS children., Method: Twenty-nine patients with DS and 15 non-affected subjects were assessed using 3D Gait Analysis, using an optoelectronic system, force platforms and video recording. The degree of flat foot was assessed using the arch index and kinematic and kinetic parameters were identified and calculated from 3D Gait Analysis for each study participant., Results: Data showed that ankle plantarflexion moment and ankle power during terminal stance were significant to differentiate the patients with and without flat feet: their peak values were significantly lower for the patients with flat foot. In addition, the research for correlation demonstrated that the higher the arch index value, the lower the peak of ankle moment and of the generated ankle power during terminal stance and the minimum of absorbed ankle power., Conclusions: Children with flat foot displayed a less functional gait pattern in terms of ankle kinetics than children without flat foot, suggesting that the presence of flat foot may lead to a weaker efficient walking. Then, the increasing flat foot tended to result in lower push-off ability, leading to a less functional walking., (© 2013 The Authors. Journal of Intellectual Disability Research © 2013 John Wiley & Sons Ltd, MENCAP & IASSIDD.)

25 children aged 2 to 5 years were examined orthopedically using the methods of plantometry and holographic interferometry of three-dimensional casts of footprints. The computer maps of the foot arch surface were obtained and the graphic reconstruction of the arch shape was performed in normal cases and in children with flatfoot. Most significant deviations of the foot arch shape, probably associated with the development delay, were detected in 4-5-year-old children under the dynamic load. Some additional advantages of holographic interferometry for the early diagnosis of flatfoot in children were demonstrated.

Background: Multiple intrinsic and extrinsic soft tissue structures that apply forces and support the medial longitudinal arch have been implicated in pes planus. These structures have common functions but their interaction in pes planus is not fully understood. The aim of this study was to compare the cross-sectional area (CSA) and thickness of the intrinsic and extrinsic foot muscles and plantar fascia thickness between normal and pes planus feet., Methods: Forty-nine adults with a normal foot posture and 49 individuals with pes planus feet were recruited from a university population. Images of the flexor digitorum longus (FDL), flexor hallucis longus (FHL), peroneus longus and brevis (PER), flexor hallucis brevis (FHB), flexor digitorum brevis (FDB) and abductor hallucis (AbH) muscles and the plantar fascia were obtained using a Venue 40 ultrasound system with a 5-13 MHz transducer., Results: The CSA and thickness of AbH, FHB and PER muscles were significantly smaller (AbH -12.8% and -6.8%, FHB -8.9% and -7.6%, PER -14.7% and -10%), whilst FDL (28.3% and 15.2%) and FHL (24% and 9.8%) were significantly larger in the pes planus group. The middle (-10.6%) and anterior (-21.7%) portions of the plantar fascia were thinner in pes planus group., Conclusion: Greater CSA and thickness of the extrinsic muscles might reflect compensatory activity to support the MLA if the intrinsic foot muscle function has been compromised by altered foot structure. A thinner plantar fascia suggests reduced load bearing, and regional variations in structure and function in feet with pes planus., (Copyright © 2014 Elsevier B.V. All rights reserved.)

Adult acquired flatfoot deformity (AAFD) is a degenerative disease resulting in malalignment of the mid- and hindfoot secondary to posterior tibial tendon dysfunction and increasing implication of ligament pathologies. Despite the complex 3D nature of AAFD, 2D radiographs are still employed to diagnose and stage the disease. Computer modeling techniques allow for accurate 3D recreations of musculoskeletal systems for the investigation of biomechanical factors contributing to disease. Following Institutional Review Board approval, the lower limbs of six diagnosed AAFD sufferers were imaged with MRI, photographs, and X-ray. Next, a radiologist graded the MRI attenuation of eight soft-tissues implicated in AAFD. Six patient-specific rigid-body models were then created and loaded according to patient weight, graded soft-tissues, and extrinsic muscles. Model function was validated using clinically relevant kinematic measures in three planes. Agreement varied depending on the measure, with average absolute deviations of < 7° for angles and <4 mm for distances. Additionally, the clinically favored AP talonavicular coverage angle, ML talo-1st metatarsal angle, and ML 1st cuneiform height showed strong correlations of R(2) = 0.63, 0.75, and 0.85, respectively. Thus, computer modeling offers a promising methodology for the non-invasive investigation of in vivo kinematic behavior in pathologic feet and, once validated, may further be used to investigate biomechanical parameters that are difficult to measure clinically., (© 2013 Orthopaedic Research Society. Published by Wiley Periodicals, Inc.)

Introduction: Foot disorders are common among older adults and may lead to outcomes such as falls and functional limitation. However, the associations of foot posture and foot function to specific foot disorders at the population level remain poorly understood. The purpose of this study was to assess the relation between specific foot disorders, foot posture, and foot function., Methods: Participants were from the population-based Framingham Foot Study. Quintiles of the modified arch index and center of pressure excursion index from plantar pressure scans were used to create foot posture and function subgroups. Adjusted odds ratios of having each specific disorder were calculated for foot posture and function subgroups relative to a referent 3 quintiles., Results: Pes planus foot posture was associated with increased odds of hammer toes and overlapping toes. Cavus foot posture was not associated with the foot disorders evaluated. Odds of having hallux valgus and overlapping toes were significantly increased in those with pronated foot function, while odds of hallux valgus and hallux rigidus were significantly decreased in those with supinated function., Conclusions: Foot posture and foot function were associated with the presence of specific foot disorders.

Background: Lateral column lengthening procedures have been extensively reported either as primary procedures or adjuncts to combined soft tissue procedures and osteotomies for the correction of the pes planovalgus deformity. There is also considerable debate as to the ideal procedure that is not followed by recurrence and obviates the need for revision surgeries and minimizes complications. We describe a technique and present the clinical results of lateral column lengthening that provides a powerful correction to restore normal foot alignment., Methods: We retrospectively reviewed 26 feet in 21 patients with a mean age of 35.4 years (range, 12-75) over an average follow-up period of 71 months (range, 12-147) who underwent reconstructive surgery for flexible pes planovalgus foot. The reconstructive procedures included a central calcaneal osteotomy in all patients, a medial column stabilization procedure, flexor digitorium transfer (FDL), and a gastrocnemius or Achilles tendon lengthening. Clinical evaluation was carried out with the AOFAS ankle-hindfoot scores. Standard weight-bearing anterior posterior (AP) and lateral radiographs before surgery and at follow-up were analyzed for radiographic parameters of correction., Results: The median AOFAS score increased from 50 to 90. Two patients reported dissatisfaction with the result. There were no nonunions nor complications related to hardware. Radiographic improvement of the talonavicular coverage angle was a 74% change from baseline value. All radiographic parameters improved (P < .001) except the lateral talocalcaneal angle (P = .48). No secondary subsidence of the arch was observed within the follow-up time., Conclusion: Correction of flexible pes planovalgus deformity with a central calcaneal osteotomy was an effective, reproducible method to restore normal foot alignment and good function., Level of Evidence: Level IV, retrospective case series.

Poly-L-lactide (PLLA) is one of the most used polymers for biomedical application; its use in sutures and other implants has been widely investigated. Although the knowledge of PLLA biodegradation and biocompatibility features is deep, PLLA screws used to correct the flat foot deformity have deserved attention since they are not degraded in most of cases after a long period of years (3-7) from the implantation. In this article, a clinical and radiological evaluation (NMR, histological and clinical outcomes) on patients was correlated with physico-chemical characterization (by SEM, DSC, GPC and XRD analysis at different temperatures) on both native and patient-recovered screws together with the theoretical degradation processes of PLLA-based implants. The data demonstrated the need for crossing the biodegradation and bioabsorption of the polymer with the characteristics of both the device (geometry, structure and fabrication process) and the implantation site., (Copyright © 2012 Elsevier B.V. All rights reserved.)

We compared bone and articular morphology of the talus and navicular in clinically diagnosed flatfeet and evaluated their potential contribution to talo-navicular joint instability. We used CT images to develop 3D models of talus and navicular bones of 10 clinically diagnosed flatfeet and 15 non-flatfeet. We quantified their global bone dimensions, inclination and dimensions of the articular surfaces and their curvatures. Additionally, ratios of six talar and navicular dimensions were calculated. The values for these parameters were then compared between both groups. In flatfeet, the talar head faced more proximal and its width was larger compared to non-flatfeet. Also the navicular cup faced more proximal and its depth was significantly increased. Furthermore, we observed a more protruding talar head compared to the navicular cup in the control group with the articular surface depth being relatively larger for the navicular cups when compared to the talus in flatfeet. The ratio of the talar and navicular articular surface height was decreased in flatfeet, suggesting increased height of navicular cups relative to the articulating talar heads. Our results show that flatfoot deformity is associated with morphological changes of talar and navicular articular surfaces that can favor medial arch collapse and forefoot abduction., (Copyright © 2012 Orthopaedic Research Society.)

Background: Idiopathic flexible flatfoot in children most frequently improves with age and remains asymptomatic. It is a physiological variation of the normality that does not require treatment unless it becomes symptomatic. The aim of this research was to investigate the reason why some individuals with flexible flatfoot become symptomatic by analysis of the differences in the relative alignment of each segment of the foot between symptomatic and asymptomatic patients with idiopathic flexible flatfoot using radiographic measurements., Methods: One hundred patients with idiopathic flexible flatfoot were retrospectively identified and divided into two groups: asymptomatic (n = 50) and symptomatic (n = 50). Standing anteroposterior and lateral radiographs of the foot were analyzed. Five measurements were calculated to describe the alignment of the foot. An independent-samples t-test and Logistic regression test were used for statistical analysis., Results: Age and sex were similar in the two groups. The independent-samples test revealed significant differences in two parameters: the anteroposterior talonavicular coverage angle and the lateral talo-first metatarsal angle. When the Logistic regression test was performed, only the talonavicular coverage angle showed statistical significance., Conclusions: The lateral displacement of the navicular bone, measured by the anteroposterior talonavicular coverage angle, seems to be related to the onset of symptoms. In individuals with otherwise normal flexible flatfoot, an increase in this angle might be an important risk factor for developing symptoms.

Background: The pediatric flat foot frequently presents as a common parental concern in the health care setting. Foot orthoses are often used, yet benefits are uncertain and disputed, having been variably investigated. A recent Cochrane review cites limited evidence for nonsurgical interventions. This critical and structured review evaluates the effect of pediatric foot orthoses from assessment of the current literature., Methods: A systematic search of the following electronic databases: Medline, CINAHL, AMED, and SPORTDiscus, using an array of search terms. A further search was also performed on relevant reference listings. Inclusion criteria were peer-reviewed journal articles, publication date from 1970 onwards, in the English language. Exclusion criteria were surgery interventions, adult subjects, rigid flat foot, articles based on opinion. A structured Quality Index was used to evaluate the research quality of articles. Three reviewers independently assessed the studies with disputes resolved by majority consensus. Studies were then grouped according to the outcome measures used., Results: Thirteen articles, from an initial 429, met the criteria for quality evaluation. The mean Quality Index score was 35% (range: 13% to 81%), indicative of generally poor and varying methodological quality., Conclusions: The low quality of the studies negates definitive conclusions. Only 3/13 quality evaluations scored > 50%; hence, evidence for efficacy of nonsurgical interventions for flexible pediatric flat feet is very limited. Future research needs validated foot type assessment, applicable outcome measures for the intervention, the use of control groups, allowance for independent effects of footwear, age range comparisons, larger samples, and prospective, longer follow-up., Clinical Relevance: There is very limited evidence for the efficacy of nonsurgical interventions for children with flexible flat feet. Clinicians need to consider the lack of good-quality evidence in their decision-making for the management of pediatric flat foot.